Prevention of Catheter-Related Infections in the Adult and Pediatric Population

1. Prevention of Catheter-Related Infections in the Adult and Pediatric Population Darcy Doellman RN BSN PICC/CVC Resource NurseCincinnati Children’s Hospital Medical Center

2. Central Venous Catheters Background & Complications • Essential in managing chronic & critically ill patients • 41% of PICU patients have 1 or more CVC • 57% of adult ICU patients have 1 or more CVC • Complications: • Mechanical (migration, hole in catheter) • Catheter obstruction, occlusion & thrombosis • Catheter-Related BSI

3. Catheter-Related InfectionsClinical Implications • Medical costs up to $25,000 to treat a Catheter-related infection • Average rate of CR-BSI is 5.3/1,000 catheter days in the ICU, approx 80,000 CR-BSI occur annually in the US • Morbidity • Mortality • Terminology

4. Noscomial Infections • Vast majority of noscomial infections are device or procedure related • Twenty fold increase of candida since 1965

5. Short-term Tunneled Implanted CVCs Catheters Ports Site Preparation Infection Control Issues PICCs Dwell Times 30+ days 1+ years 1+ years 3+ years Reported 4 days 6 weeks 6 months 3 years mean Rate of 5.3/1000 0.51/1000 2.77/1000 0.21/1000 catheter catheter catheter catheter CR-BSI days days days days Insertion Bedside Bedside IR/OR IR/OR Issues Medical Nurses Medical Medical Providers Providers Providers CSR-BSI Considerations and Central Venous Access Devices Sources: CDC 2002, Moreau, 2002, Ryder, 1996, Lowenthal et. Al. 2002, Skiest, 2000, Thiagajarian, 1997,Alhimyary, 1996, Abi-Nader, 1993, Ng, 1997, Graham, 1991

6. Desired Outcomes: Provide best care possible Evidence-based practice Minimize complications of central lines Reality We use what’s available Unaware of complications Limitations of literature Do not consider overall costs Practice Issues

7. Challenge for Clinicians • Multi-tasking • Information overload • Time intensive • Staffing issues • Experienced personnel

8. Catheter OcclusionPrevention – CCHMC Studies

9. INCIDENCE OF CR-BSI • Catheter duration (Raad et al J Hosp Infect 1993) • Insertion Site ( IJ site associated with fourfold increase as compared to subclavian site) • Geography (Mermel et al Am J Med 1991) • High risk patients • Multiple lumens/catheters • Catheter material (polyvinyl chloride or polyethyl) Thrombogenicity/phlebitis

10. CR-BSI • Microbes colonize skin at the insertion siteand the catheter hub (Mermel et al Am J Med 1991) • Sutures go through skin, inflammation

11. Biofilm Basics • Planktonic and sessile cells interact • As sessile bacteria attach to a surface, they begin to excrete a slimy material (biofilm). Single cells – Early structure – Mature biofilm (nutrients flow through complex structures) • Researchers have shown that bacterium attached to a surface “turns on” a whole different set of genes. This makes it a different organism to deal with

12. Free Floating Ubiquitous Planktonic Rapid growth Fairly sensitive Embedded Ubiquitous Sessile Phenotype Slow growth Highly resistant Biofilm Lifestyles

13. Biofilm Basics • Researchers at the “Center for Biofilm Engineering” have discovered a different level of expression of genes, a division of labor • Some cells use energy turned on by metabolic pathways and effects the partial degradation while others use the degradation products to produce new cells (cell to cell communication)

14. BIOFILM • The “Iceberg Effect” • Described by Maki and Mermel • Difficult to treat, best to remove it. Patient may be asymptomatic • Cultures may grow planktonic cells • Biofilm in “high flow” areas may seed other parts of the body

15. FUTURE TREATMENT • Biofilm inhibitor (RAP, TRAP, RIP is biofilm inhibitor) • Biofilm inhibitor plus antibiotic in dacron cuff • With the use of ultrasound, the inhibitor and antibiotic would be released • Biofilm inhibitor in antibiotic beads as they dissolve

16. Handwashing Chlorohexidine scrub (1a recommendation from the CDC) BioPatch (chlorhexidine-impregnated synthetic disk) Anti-infective lock solution in long-term devices Maximal sterile barriers Specialty teams Multidisciplinary approach Transparent dressing Antimicrobial-infected catheters Securement devices Prevention

17. Handwashing • 50% of nosocomial infections could be eliminated by handwashing alone • Hands are only washed 50% of the times indicated • Wearing gloves does not eliminate need to wash hands before or after patient contact • 15 second vigorous hand wash with soap and running water • Primary infection control measure

18. Chlorhexidine Skin Antiseptic • Superior efficacy • Rapid onset (30 seconds) and prolonged antimicrobial efficacy • Recent meta-analysis suggest CR-BSI is significantly reduced in patients receiving chloraprep vs providine-iodine for site disinfection • 80% of resident and transient flora live in the 1st 5 layers of dry skin (1st 10 layers of wet skin) Friction is necessary (Chalyakunapruk N, et al. Ann Intern Med. 2002;135, 792)

19. BIOPATCH • Foam patch with chlorhexidrine gluconate with antimicrobial and antifungal properties • Highly absorbent • Inhibits growth of bacteria for 7 days • Shown to significantly reduce bacterial colonization of CVC sites (Hanazaki et al, J Hosp Inf 1999) • Associated with localized contact dermatitis in infants of very low birthweight (Garland et al, Pediatrics 20010

20. ANTI-INFECTIVE LOCK SOLUTION • Prophylaxis with vancomycin lock (More studies needed) Risk of VRE • Ethanol instillation (to be published soon) 25% ethanol instilled for one hour each day

21. PREVENTION • The use of maximal sterile barrier, including the use of hair covering, face mask, sterile gown and gloves and large sterile drapes, have been shown to reduce the risk of infection by six to seven times over the use of sterile gloves and drapes alone (Maki, 1994) • AHRQ

22. SPECIALTY TEAMS • IV Teams/PICC teams • Clinical resource for clinicians • Routine assessment of CVC sites • Monitoring of CVC for potential complications • Goal is to provide appropriate access from the start

23. Uniform Guidelines INS Standards/ CDC Guidelines Policies available and user-friendly Yearly competencies Resources available Process Improvement Ongoing educational opportunities PREVENTION

24. PREVENTIONEDUCATION • Mandatory education program for ICU nurses and physicians in a 19-bed medical ICU at Washington University • 10-page self-study module on risk factors and practice modifications relating to CR-BSI and inservices • Pre and post-test. Fact sheets and posters reinforced the information • Results: 24 months before the education, CR-BSI occurred in 9.4/1,000 catheter days ( 74 in 7,879 catheter days) After implementing new program, CR-BSI occurred in 5.5/1,000 catheter day (41 in 7,455 catheter days) • Estimated cost savings with decreased CR-BSI was between $103,600 and 1,573,000. • Warren DK. “The Effect of an Education Program on the Incidence of Central Venous Catheter-Associated Bloodstream Infections in a Medical Center.” Chest 2004;126: 1612-1618.

25. TRANSPARENT DRESSING • Semi-permeable polyurethane dressings • Dry and intact • Routine dressing changes • Special attention to immunocompromised patients and neonates

26. Purpose: Evaluate efficacy of long-term non-tunneled silicone catheters impregnated with minocycline and rifampin (M-R) in reducing CR-BSI Prospective, randomized, double-blind study N=356 182 M-R Catheter duration 66.21 days CR-BSI 3 174 control Catheter duration 63.01 days CR-BSI 14 Hanna H, et al. “Long-term silicone central venous catheters impregnated with minocycline and rifampin decrease rates of catheter-related bloodstream infection in cancer patients: a prospective randomized clinical trial.” J Clin Oncol. 2004 Aug 1;22(15):.3163-71 CR=BSI rates: M-R 0.25/1,000 catheter days Control 1.28/1,000 catheter days P=.003 Gram-positive cocci accounted for the majority of positive cultures No allergic reactions ANTIMICROBIAL IMPREGNATED CATHETERSPREVENTION

27. ANTISEPTIC IMPREGNATED CATHETERS AND CUFFS • Catheters coated with chlorhexidine/silver sufadiazine on the catheter surface can reduce the risk for CR-BSI • Antimicrobial activity decreases over time, benefit will be realized within the 1st 14 days. • Although rare, anaphylaxis has been reported • More expensive than standard catheters, may be cost effective for high risk patients i.e. patients with burns, neutropenia Veenstra DL et al, “Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related blood stream infections: a meta-analysis.” JAMA 1999;281;261-7.

28. SECUREMENT DEVICES • Decrease irritation • Decrease needlesticks • Decrease catheter migration • Increase patient comfort • Decrease infection(Shears et al, 2000)

29. Catheters inserted into new sites, not old sites over a guidewire (avoid routine replacement of central lines) Warfarin and Heparin Prophylaxis (Thrombus formation on indwelling CVC associated with CR-BSI) S. aureus, S. epidermidis, and Candida species adhere to different protein components of thrombus) Subcutaneously tunneled short term catheters (Cuffed dialysis catheters decreases risk of CR-BSI by 2/3) Minimize hub manipulations Ointments to insertion site; may lead to increased colonization of candida species.(Ointment to insertion sites of temporary HD central lines reduces CR-BSI) ADDITIONAL STRATEGIES

30. “KEEP ME SAFE” • Patient campaign from the Oley foundation • Specific instructions for central line care • Goal is to prevent infection